Premier Mental Health, Mental Retardation, and Substance Abuse Services in Virginia’s

Communities

Substance Use Disorders Treatment and Prevention

VACSBAugust 26, 2009

SJR 318 Study Committee

2

Outline• Impact of Substance Use Disorders

• Treatment Efficacy and Capacity

• Good Treatment Outcomes Need Effective Strategies

• Evidence-Based Practices; Treatment and Prevention Services Systems in Transition

• Funding, Services, Costs

• Prevention as a First Step

• Funding Options for Prevention and Treatment

3

Currents Studies Demonstrate• 704,000+ individuals in Virginia Need

treatment

• Almost 80% are not receiving treatment

• Virginia direct and indirect costs from alcohol abuse = $6 Billion

• Virginia direct and indirect from illicit drug use and = $3.5 Billion

4

Studies Demonstrate• 80% of treatment funded by

government

• 12% of treatment funded by private insurance

• Only 3% of all government funding for SUD and its consequences is spent on treatment, prevention or research

5

Virginia Studies• OIG Report (2006) -Average of 25.4

days wait time for treatment

• JLARC (2008) – Annual costs of $715 Million related to substance abuse and consequences (public $$ only)

• Less than 10% spent on treatment and/or prevention

6

National and State Studies• Individuals in treatment imposed

substantially lower net costs on state and localities (JLARC)

• Utilizing appropriate services over time results in a 60% recovery rate, higher than other chronic diseases

• But: VA community-based prevention and treatment services funding has been inadequate and erratic, directly affecting service and workforce capacity

7

Service and Funding

• In FY 2008, CSBs served 57,219 Virginians with SUDState General Funding (FY2007): 41.8M

• Other funding comes from SAPT Block grants and local funding

• Total funding from all sources (FY2008): 152.2M

8

Impact-Substance Use Disorders

• SUD involved in over 50% of violent crimes

• SUD involvement for 70% of those in local and state correctional facilities

• SUD involved in 70% of all child abuse and neglect cases

9

Treatment EfficacyAccording to OIG Report-August 2006, of

consumers with a Length Of Stay of 1.7 years in outpatient treatment services:

• 91% saw decrease in A/D use

• 64% were employed

• 86% had stable housing

• 81% had no drug-related arrests or convictions

10

Treatment Capacity: OIG Report• Over 70% of CSBs reported no or inadequate

capacity in the following, all of which have an evidence base:

• Detox, Medical or Social

• Medication Assisted Treatment

• Day Treatment, Intensive OP

• Residential

• Case management

• Services for those incarcerated

11

Treatment Capacity: OIG Report

• Elimination of SABRE Funding from FY 2002 to FY 2003 resulted in the lost of 92.62 staff positions, the elimination of 36 service programs, and the capacity to treat 13,161 clients (6,425 youths, and 6,736 adults).

• Current average wait for treatment services is 25.4 days (OIG Report, 2006)

12

Milestones: 2000’s• General Assembly legislation included substance use

disorder in insurance parity (disease-based research)

• Strong self-advocacy and recovery movement takes root with SAARA, Substance Abuse and Addiction Recovery Alliance, establishing local chapters in many communities throughout Virginia

• 2002-2003 budget deficit policy decisions meant abrupt elimination of SABRE funds and delay in implementing Medicaid coverage for SUD treatment services

• Private provider capacity severely damaged and CSB capacity compromised; some programs went out of business

13

Treatment and Prevention Services In Transition

• Prevention Services must involve the broader community, focus on multiple indicators of community health, and target the entire life span

• Treatment services, to date, have primarily been delivered in an acute care model of intervention: treat someone as quickly as possible, stabilize the acute stress and return them to the community

• Treatment services must transition from the acute care model to a Chronic Disease – Recovery Management Model of service delivery

• Treatment and recovery outcomes are most effective when people are engaged in both formal, structured treatment and ongoing self-help support groups

14

Key Principles of Effective Treatment• When the person is ready, treatment is available• Peer support, such as 12 step, effective in recovery

• Effective treatment attends to multiple needs of the individual - wraparound approach

• Remaining in treatment for an adequate period of time is critical for treatment effectiveness

• Monitoring and service modification

15

• Medications can be an important element of treatment

• Other health conditions related to addiction, such as TB, HIV and hepatitis B&C, addressed

• Integrated treatment for Individuals with co-occurring mental illness and substance use disorders

• Recovery from addiction can be a long-term process and frequently requires multiple episodes of treatment

Key Principles of Effective Treatment

16

• Engages the entire community, not just the schools, and the focus is expanded to view prevention services across the lifespan

• Aim is to build protective factors, promote resiliency and decrease risks

• Incorporates public health research and evidence-based prevention programs to build capacity utilizing a five step plan:

Assessment Capacity Development

Planning Implementation Evaluation

Key Principles of Effective Prevention

17

EBPs and Transformation• Numerous treatment and prevention practices have been

shown to be effective – evidence-based practices and programs (e.g., Al’s Pals, Too Good for Drugs, Use of Certain Medications in Treatment, Drug Courts, Provision of Wrap Around Supports, Contingency Management)

• Adoption of innovative, evidence-based practices (EBPs) requires organizational culture change, extensive training and supervision, and consistent leadership support

• Additional costs of implementing EBPs includes initial and ongoing training, purchase of proprietary materials, expanded types and amounts of supervision, recruitment of qualified staff, purchasing appropriate medications or manuals, and evaluation

18

SUD Funding: Federal BGSAPT Block grant funds require the following

minimums:

• 70% Treatment• Priority admission to pregnant and parenting

women and persons who inject drugs

• 20% Prevention

19

SUD Funding: MedicaidMedicaid will reimburse the following services, for

certain people (Medicaid eligible and enrolled) under certain conditions (e.g., not in residential treatment or other IMD, not in jail):

• Intensive Outpatient• Case Management • Crisis Intervention• Day Treatment• Psychiatric Services• Opioid Treatment

20

Other Effective Technologies• Drug Courts: 27 in Virginia – completion of drug

courts results in less than 5% felony recidivism rate with adherence to program

• Individuals in Recovery able and encouraged to provide professional or peer recovery support services through public and private providers

• New Crisis stabilization programs may have detox capability

• Specialized criminal justice system services, provided on-site, such as at Probation and Parole offices

21

Cost of Services: Outpatient • Outpatient or Intensive Outpatient services, with

ongoing Wraparound Supports (transportation, child care, peer supports) and Case Management, costs an average of $10,000 per person for one year, as a package of bundled services.

• 18 months to two years is the recommended length of active treatment

• Includes assessment, planning, screens, intensive counseling, transportation, child care, vocation, employment, case management

• Less costly than extended and repetitive stays in jail or state correctional facilities

22

Costs of Services: Residential• Medical detox - $286 per day (41 beds)

• Social detox - $328 per day (96 beds)

• Residential - $171.95 per day (522 beds) LOS-45 days for clinical efficacy

• These services, immediately followed with adequate Outpatient Services, have profound impact for life changes

23

Costs of Underage Drinking in Virginia: 2005

• Youth Violence $541.5• Youth Traffic Crashes $385.1• High-Risk Sex, Ages 14 to20 $117.1• Youth Property Crime $53.4• Youth Injury $43.5• Poisonings and Psychoses $11.4• Total Cost $1.226 Billion• $1,706 per year for each youth in Virginia

24

Preventing ATOD Use Funding• Federal Block Grant (SAPT) to VA of $43 million

- $8 million is required allocation for Prevention

• State Funds allocated to CSB Prevention $0

• Total estimated Prevention funding is $21.5 million as compared to Treatment funding of $175.3 million, from all sources

• Prevention funding has decreased by 16% during the past five years

25

Alcohol consumption by Youth in Virginia

• Approximately 319,00 underage youth drink alcohol each year in Virginia generating $418 million in sales

• In 2005, underage drinkers consumed 14.8% of all alcohol sold in Virginia

• 76% of 12th graders reported that they had used alcohol at some point during their life

• 44% of 12th graders reported that they had used marijuana at some point during their life

• 25% had their first drink before age 13• 18% had five or drinks in a row in the past 2 weeks

26

Un-served and Underserved Populations Needing Prevention Services

• School Dropouts (59%)

• Children of Substance Abusers (42%)

• Delinquent Violent Youth (39%)

Conclusion:

Increased funding for proven Prevention Programs will serve high-risk youth and reduce incidence of abuse

27

Options for Dedicated, Stable Funding• Establish Substance Abuse Treatment &

Prevention Fund: Require ABC Board to deduct five percent of net profits to be paid into this Fund; represents out-of-pocket costs of no more than pennies to the consumer.

• Direct additional (new) revenue from new ABC stores and Sunday opening through DMHMRSAS for treatment and prevention

• Increase user fees on alcohol products:Estimate .10 per bottle alcohol increase- $77M

28

Useful Resources• http://www.dmhmrsas.virginia.gov/documents/report

s/OSAS-BiennialReport2004-2005.pdf• http://www.oig.virginia.gov/documents/SS-

SAOP129-06.pdf• NIDA: Principles of Drug Addiction Treatment: A

Research Based Guide• NSDUH

2006http://oas.samhsa.gov/2k6State/Virginia.htm